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A 64 year old man presented with intermittent dizziness, palpitation, and dyspnoea. Three years ago, he underwent percutaneous coronary intervention with stenting for a mid right coronary artery stenosis and VVI pacemaker implantation for episodic symptomatic sinus pause. On admission, the 12 lead ECG showed a sinus rhythm with a rate of 54 beats/min (bpm). Two dimensional echocardiography revealed a dilated left ventricle with a global ejection fraction of 50% and mild mitral regurgitation. The VVI pacemaker was normal in pacing and sensing function, with pacemaker analysis and 24 hour Holter monitoring. Simultaneous recording of femoral arterial blood pressure and ECG revealed the arterial blood pressure dropped from 131/72 to 88/55 mm Hg when VVI pacing rhythm appeared, as the sinus rate slowed below 60 bpm. During ventricular pacing rhythm, retrograde p waves were discernible after the paced QRS complexes.
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